Wednesday, August 5, 2009

Understanding Conscience and Tolerance

I think in a pluralistic culture like ours, the key to understanding conscience lies in tolerance, not in trying to change anyone’s conscience decisions—but in seeing how our society can adapt.

Now in some cases, adaptation is uncalled for, e.g., if something were illegal. But isn’t the sign of a civil civic society the measures taken by individuals, institutions, and society itself to support sincere conscience decisions—if possible.

Example: I know a hospital in which an ER doctor cannot in conscience prescribe a certain medication for rape victims, claiming that it is abortifacient. Even though the hospital’s policy is that such medication be prescribed because it is not seen to be such, the doctor cannot agree.

So the ER staff have agreed among themselves that they will be available whenever a rape victim comes into the ER. I call that adaptation or tolerance.

Yes, yes, I know there are some weird “conscience decisions” out there that make “toleration” heroic. But I have argued that, with the pharmacist in the one-drug-store town who will not fulfill certain prescriptions, that’s druggist’s professional association, by certifying him/her, assumes responsibility to cover when the occasion warrants.

5 Comments:

That said, I really do not believe a health care provider should be forced to violate his conscience or the principles of his faith, nor should he or she be forced to actively facilitate a patient in doing something the health care provider feels, as a matter of conscience and faith, the provider feels to be inherently immoral.

As for religious hospitals affiliated with Churches which condemn abortion in (essentially) all instances (Roman Catholic Missouri Synod Lutheran, Southern Baptist, other Churches,) I feel they should not be forced to violate the official tenets of their faith. To me, that raises to the level of persecution against the (sponsoring) Church in violation of the 1st Amendment to the U. S. Constitution. After all, the patients surely know enough to go elsewhere if the services and medications they request are denied for "faith based" reasons, or if they can reasonably presume they will not be available. For a patient or an advocacy group to try to force things through direct action as a form of protest is, to me, not appropriate.

If this is felt not to be acceptable, the way to change things is not through coercieve governmental or political means, but by working through the Church's own internal mechanisms, using each Church's own "due process" to change the Church's doctrine.

If that does not work, the hospital/clinic has the option of disassociating/dropping their affiliation with their sponsoring Church (or the sponsoring Church can drop its sponsorship/affiliation of that health care facility.

I do not believe any professional organization, as part of certification, asks for or requires an oath to act in a way contrary to one's conscience. Most medical professionals resolve to "First do no harm", rather than proceed with dubious action for personal gain or profit. I suspect there are few small towns so isolated that a neighboring pharmacy within reasonable distance would not be available.R Pierron MD

I want to point out the difference between state licensure and private association membership, given your comment:

"druggist’s professional association, by certifying him/her, assumes responsibility to cover when the occasion warrants."

Professional associations are, by definition, voluntary and typically don't involve anything more than being licensed and paying dues. Most pharmacy societies, for example, don't "certify" anything at all. Being a member is a form you fill out and send in, with a check. Of course there is a code of ethics, which the association has neither the resources, nor the incentive, to enforce.

The issue here is, I respectfully suggest, far more focused than the previous commenters suggest. The issue is when the patient wants one thing, and the provider does not want to provide it, because of religious conviction which is not unanimously, or even predominantly, held.

Most Americans believe that abortion is, ultimately, a decision to be made by the pregnant woman, and should not be imposed upon her by anyone, government, religious organization, or healthcare provider. People are deeply ambivalent about this decision when asked if they would choose it for themselves, but when the question is properly asked, Americans are overwhelmingly in favor of putting this decision in the hands of those who must live with it: pregnant women.

The idea that state-licensed professionals can obstruct that decision is anathema to most people, when they think about it in these terms.

Hospitals are actually few and far between in most of the world, including the US. When you go there, you are stuck. Pharmacies are somewhat more available, at least during business hours, but you'd be surprised at the number of smaller towns with only one, and where the next one is a gallon of gas to get there, and another gallon to get back.

All of us professionals (I'm a lawyer) expect to have to put aside our own beliefs in the interests of helping our clients/patients. This is what being a professional is all about: subordinating yourself in service to others. That's why Jewish ACLU lawyers defend Nazis, and why Roman Catholic physicians perform abortions, when no one else can be found to do so. If you aren't willing to do that, you aren't a true professional, and should find another occupation.

Arthur ThextonMadison, WI(for 18 years, a prosecutor for the Wisconsin Department of Regulation & Licensing, serving the Medical, Pharmacy, Nursing, and other health care licensing boards.)

I appreciate Mr. Thexton's comments. In fact patients are instructed in general where to go by insurance companies; and there are in the Great Plains and the American Southwest places where the next pharmacy might be 50 miles or more away - a distance that might be a significant problem.

I would say, though, to Mr. Thexton that there are professional associations that take on responsibility for certifying the professional qualifications and professionalism of members. This is especially true in medicine, as well as in some other professions. If as a Board Certified Chaplain I violate the Code of Ethics of the Association of Professional Chaplains, I can lose that certification and thus lose my job. It would also be reported to the faith community in which I am ordained, and so have other consequences.

Even as clergy, we are taught the concept of "fiduciary responsibility," that Mr. Thexton knows well: the responsibility to serve the needs of the person we serve, even at the expense of our own. Whether overseen by state licensure or professional certification, many of us are still processional responsible for that.

About Me

The Center for Practical Bioethics is a nonprofit, free-standing and independent organization nationally recognized for its work in practical bioethics. Since 1984, the Center has helped patients and their families, healthcare professionals, policymakers and corporate leaders grapple with ethically complex issues in medicine and research.
For more go to www.practicalbioethics.org.
The editor of this blog is John Carney at the Center. For questions or suggestions, email jcarney@practicalbioethics.org.